Thursday, April 25, 2013

Daily Summary

Is PrEP an essential component of Treatment as Prevention?

The final day of the International Treatment as Prevention Workshop began with a debate asking whether PrEP is an essential component of Treatment as Prevention.

Dr. Robert Grant, a professor of medicine at the University of California–San Francisco, presented the case for PrEP in TasP, referencing trials that demonstrated its effectiveness and feasibility. He described PrEP as a game-changer because of its potential to decrease the burden on treatment programs, motivate HIV testing, and provide more timely identification of acute infections. Most importantly, Dr. Grant argued, PrEP may destigmatize HIV.

Dr. Brian Williams, an epidemiologist at SACEMA (Cape Town), argued against PrEP being an essential part of TasP, framing the debate as an either/or scenario. He advised the goal of HIV control should be to ensure universal access to ARVs and to have people treated as early as possible, an objective best achieved through Treatment as Prevention. This approach, he said, is more effective at reducing new HIV transmissions than PrEP. Limited resources should be directed toward the more cost-effective TasP approach which will, in the long term, lead to the elimination of HIV/AIDS.

The debate was followed by two abstract-driven sessions to close out the morning.

Evolving HAART guidelines and TasP

The afternoon began with a roundtable session on evolving HAART guidelines. Dr. Reuben Granich of UNAIDS presented the latest global guidelines for ART initiation, summarizing the varying ART initiation policies of 72 nations. While noting that many countries have moved toward early initiation policies, Dr. Granich cautioned that much work is still to be done to increase coverage for pregnant women, HIV and TB coinfection, and serodiscordant couples. He also pointed out highly impacted groups including sex workers, men who have sex with men, and injection drug users, still remain excluded from guidelines. He concluded by stating that a Treatment as Prevention policy is important to secure funding, and UNAIDS will work on the acceleration of science to policy.

Dr. Granich was followed by presentations from Dr. Charles Holmes and Theo Smart on the topic of whether the new guidelines are affordable. Dr. Holmes, Director of CIDRZ in Zambia, presented on the affordability and cost-effectiveness of early ART initiation. Using the Zambia example from the PopART study, he showed comparisons of eligibility threshold changes coupled with uniform expansion of testing that demonstrated the most cost-efficient approach is immediate treatment of all HIV-positive individuals.

Theo Smart, a science writer and activist, provided the community perspective on the affordability of the proposed new ART initiation guidelines. Mr. Smart argued that people should have the opportunity to receive treatment when they are ready for it, and called upon the scientific community to develop simpler, more affordable regimen options.

Community peer-based efforts

The second afternoon session turned the focus to community and peer-based efforts to implement Treatment as Prevention. The first speaker, Daniel Ochieng Ofuwo, presented the AMPATH Plus initiative in Kenya. The objective of this community-based, peer-led initiative is to encourage HIV treatment adherence to improve health outcomes and reduce new HIV transmissions. In a country that has experienced approximately 66,000 new HIV infections annually, one-third of whom are not actively engaged in care. Mortality among those newly diagnosed is twice as high if just one clinic visit is missed within the first year, creating urgency for engagement into care.

Dr. Maria Campos spoke about efforts in Portugal to implement community-level Treatment as Prevention in men who have sex with men. The goal in the Lisbon-based initiative is to promote early HIV detection in this highly impacted group. Outreach efforts have targeted bars, saunas, and other cruising locations with the intention to encourage HIV testing, provide advice and support, and connect individuals to HIV care.

Paul Kawata, Executive Director of the U.S.-based National Minority AIDS Council, spoke from the community perspective. He argued for the need to develop scalable Treatment as Prevention efforts, particularly in context of the U.S. goal to engage 300,000 HIV-positive individuals into treatment and care. He left researchers with a question and a challenge: How are we going to end the epidemic when the community we need to target doesn't care anymore?

Financing: More money or more ‘bang for the buck’?

The final session of the Treatment as Prevention Workshop explored the question of financing. Dr. Catherine Hankins, Deputy Director of Science at the Amsterdam Institute for Global Health and Development, presented on recent trends in development assistance. She argued international HIV assistance remains critical, particularly in sub-Saharan Africa and Southeast and South Asia. She pointed to demographic trends showing new HIV transmissions growing in middle income countries. Dr. Hankins called for efficient investment in HIV programming that is country-driven and tailored to epidemic dynamics for maximum impact.

Meredith Moore of the Clinton Health Access Initiative (CHAI) spoke about cost frameworks for HIV Treatment as Prevention. She presented HIV drug pricing trends, and the long term goal to develop new regimen compositions and new drug formulations to improve treatment affordability.

Matthew Kavanagh of the U.S.-based Health GAP spoke about efficiency and the need to do more with less. Newer drugs, he said, can help Treatment as Prevention efficiency by achieving cost-savings through better uptake and fewer clinic visits. Mr. Kavanagh called for the scientific community to engage and champion the Treatment as Prevention strategy in terms of “pay now or pay forever”.

Dr. Denis Broun, Executive Director of UNITAID, spoke to the need to focus on more effective ways to raise money and more effective ways to spend money. He argued that resources should be directed to areas where Treatment as Prevention will be the most cost-effective, areas where there are higher rates of HIV transmission with the potential to have the maximum impact over a minimum length of time.

Following the open discussion, Dr. Julio Montaner gave the closing remarks for the International Treatment as Prevention Workshop.

2013 ConsolidatedARV Guidelines forHIV Treatment and Prevention

On Day One of the Treatment as Prevention Workshop, the scientific session was opened by Dr. Meg Doherty (Coordinator of the Treatment and Care Team at WHO’s Department of HIV/AIDS). The presentation focused on the “2013 Consolidated ARV Guidelines for HIV Treatment and Prevention”, which will provide clinical, operational, and programmatic guidance for scaling up HIV programs in low and middle income countries following a public health approach.

This guideline will be officially launched at the IAS Conference on HIV Pathogenesis, Treatment and Prevention in Kuala Lumpur in July 2013. During a preview of changes in this guideline, Dr. Doherty indicated WHO may raise the treatment initiation threshold for HIV-positive individuals from a CD4 count of less than 350 to a count of less than or equal to 500. This would allow people with HIV to start treatment earlier in the course of HIV disease. The consolidated guidelines may also support triple ARVs for all pregnant women and ART for all children less than 5 years old. Additionally, treatment initiation will be a consideration in specific circumstances regardless of CD4 count (i.e. serodiscordant couples, TB coinfection). WHO may further support the increased use of viral load for monitoring treatment response and detecting treatment failure.